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Type of Business or Property SERVICE REQUEST <br /> FACILITY ID# SERVICE REQUEST#r f ESILUNGLAR : <br /> ES1O�r1A t- 2 c �� �coOWNER IOPERATOR <br /> A ./ f�P/-dpiu-mFDS <br /> FAcury NAME <br /> StrE ADDER¢ S <br /> 1 <br /> Stoat NumA � I TClfg-L G- <br /> StrM rums <br /> [wiling Address (If Different from Site Address) Troy svn�s <br /> Crry STATE ex ZIP <br /> PHONE#'I En. APN# LAND USE APPLICATION# <br /> A11A <br /> PHONE#2 BOUISTRJCT LOCI,TIOr1 CbDE <br /> CONTRACTOR r SERVICE REQUESTO R <br /> FZEQUESTOR `! HILLWG PARTY <br /> 6usiNEss NAME � l <br /> V>� 4L� ��f��,�C�-/ PHONE# Err. <br /> MA iNGADDRESS FAx# (� <br /> 6g--z5 <br /> CITY I R STATE CA ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner,operator or authorized agent of same,acknowledge that all site and/or project spe ric <br /> PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DMSION hourly charges associated with this projector activity will be billed to me or my business as identified on thts form. <br /> I also certify that I have prepared this ap ' n and that the w performed will be done in accordance with all SAN JOAOUIN COUNTY Ordinance Codes,Standards,STATE and ; <br /> FEDERAL laws. <br /> APPUCAk7 SIGNATURE: <br /> DATE: <br /> PROPERTY IBUSINESS OWNER D OPERATOR/MANAGER OTHERAUTHORREDAGENT D <br /> IfApar-wrisnot ft tFrrl Fvuo/ofaufhoru:flanfoslpnlsmquhad rifle <br /> AUTHORIZATION TO RELEASE INFORMATION.When applicable,I,the owner or operator of the property located at the above site address,hereby authorize the release of <br /> any and all results,geotechnical data and/or environmentaUsite assessment information to the SAN JOAQUIN COUNTY PUOLIC HEALTH SEFMCES ENVIRONMENTAL HEALTH DmsioN as soon <br /> as it is available and at the same time it is provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: <br /> /V/ T'kA L O A /Vd/L Gd L TLC D /-7E(f <br /> COMMENTS: <br /> PAYMENT <br /> W�°v. RECEIVED <br /> /� �� f DEC 12 2000 <br /> L11 <br /> /� AOUIN CC)UNTY <br /> (f V SAN TH SF:4iVlCtS <br /> PUaL10}iE�,L <br /> ENVIRDPIh&E Jf,L YEALTN pl1rISIDN <br /> INSPECTORS SIGNATURE: CONTRACTORS SIGNATURE: <br /> APPROVED BY:. <br /> EMPLOYEE#: �' y DATE: <br /> ASSIGNED 70: C—� �` ` EMPLOYEE#: ? \ DATE: j <br /> Date Service Completed (if already completed); SERVICE CODE: P I E:2 bUz <br /> Fee Amount: Amount paid f�f <br /> Payment Date r�1 I b� <br /> Payment Type Invoice tl' ;Check;d 147D... <br /> _ q 1 <br /> Received By: <br /> 3 <br />